I felt a little sad when I read the “perspective” piece in the New England Journal of Medicine this week about the introduction of point-of-care ultrasound in medical education.

In it, two cardiologists from the Brigham and Women’s Hospital review the promise and some of the challenges of incorporating hand held ultrasonography into medical education and, more broadly, into medical practice. For those of you unfamiliar with the technology, this is not your father’s ultrasound machine. I grabbed this picture from the website of the GE device:

The authors cite a number of studies that support the utility of the technology and, rightfully, liken it to an extension of the stethoscope. It is not a big surprise that it allows for more accurate assessments of things like left ventricular systolic performance or liver size than can generally be achieved with physical examination. So what’s the problem?

I do, however, consider myself a rather old-fashioned kind of physician. I no longer perform any high-tech procedures (I am a “lapsed interventional cardiologist”); I am not an early adopter of newly approved medications; I am a generally skeptical reader of the medical literature; and I believe in the power of listening to patients and doing a good physical examination in forming a therapeutic relationship.

I think my discomfort with point-of-care ultrasound supplanting the stethoscope comes down to a somewhat irrational sense that using it in everyday patient encounters feels a little like cheating. It has taken me years of training and practice to feel confident in my auscultatory skills, and it is not a coincidence that I named this blog “Auscultation.” Those skills are part of what help define me as a physician, and the sadness I feel reflects a decline in their value. Who cares if you can hear an opening snap, if you can see on the screen that the patient has mitral stenosis? I know in my head that it is better for the patient if it is easier to make the right diagnosis. My heart is telling me something else.

What do you think?

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19 thoughts on “Death of the stethoscope?”

opening your email blog literally seconds after I purchased a new stethoscope (my first in 30 years after it literally distintegrated) was a bit spooky I have to say……I wholeheartedly agree with your sentiments (obviously).
JWA

Just as learning to auscultate the heart is a skilled learned over years of practice, cardiac ultrasound is no quick skill. Manipulating a probe across the chest to diagnosis valve disease is a significant task. An echocardiogram should not be ordered blindly but in the context of a patient history and auscultative findings. A poorly done echo can result in unnecessary procedures and wrong diagnosis. The “ultrasound auscultation” may enhance but should not replace the stethoscope. There is an art to medicine and part of that art includes listening to the patient. Stethoscope required.

Thanks for this perspective. I did not mean to imply that there was no skill required to perform an effective exam via ultrasound. I certainly learned that as a cardiology fellow! Even so, it still seems that “doing it the old fashioned way” is more challenging. It is also interesting to speculate to what extent ultrasound will complement rather than supplant the stethoscope. Maybe the stethoscope will become more like the white coat — a professional symbol more than an essential tool.

I was an abused child in the 1940s. My doctor and teachers reported this about my brother and I, but it was like present day stalking-nothing could be done unless she killed one of us. We knew that we could call our doctor, and he’d make a house call. Mother took us in, so she’d look good. While the doctor looked at our injuries, he had his nurse help my mother fill out a stack of medical history.

There was something comforting about the stethoscope, saying ‘ahh’ even though we gagged on the speculum. There was something about breathing in-Take a deep breath- hold it- breathe out. It was calming, comforting-it gave us hope. A tender touch, an encouraging word.

Now I go into a PCP, and I complain of a sore throat. They stare at me. It doesn’t have anything to do with the EHR-the computer in the office. It’s the distance-like they will catch old age from me-I had strep for 5 months because of this. I finally ran into a Dr. that did med 101-and ran a strep test-it was acute.

Sometime about 2006, before EHRs, I stopped feeling safe. I bathe daily, brush my teeth several times a day. I have some trouble with my hair-thyroid. I’m not the only old lady with dog biscuits in my pocket-at least I’m not eating them.

They make me feel insecure, they make me feel diseased. I don’t know what will set them off and start an argument.

I wish that these doctors would read William Carlos Williams of New Jersey. -poet and a great MD. But they don’t–

This touches on a really important aspect of auscultation — the need to get intimate with the patient to use a stethoscope. I believe that a good physical exam has therapeutic as well as diagnostic value. The physician must “lay on hands” to examine the patient, which creates a powerful bond. Many have complained that technology has diminished this bond, and there is risk that the substitution of a probe for a stethoscope may do the same.

Exactly, how can you relax, if you don’t feel safe? It’s more than a good bedside manner. I’ve had some gruff or cold distant doctors that ended up giving me a feeling of safety, and part of that safety is checking my lymph glands and using the stethoscope. A soft-spoken doctor can be rough or dismissive during this exam, while someone that seems distant or gruff can be thorough and gentle.

The auscultation helps the patient to relax and show trust in the doctor, while the healing hands transfers the doctor’s skill and concern to the patient.

I am of 2 monds on the issue. On the one hand, a stethescope is simply a piece of 19th century technology; its works well. and 2 generations ago doctors were much better at using it sine it was the best they had. Many things have there time and then we move on. Anyone yuse Morse Code today? How about a CB radio?

On the other hand, the stethscope’s day is not over. It’s still a pretty good tool, and while my skill at heart murmurs wont match those of older doctors, its still a good tool for me to checl blood pressure, listen for wheezing or crackles, or listen for a prominent P2 that tells me that my patinet needs an echo. Dont count it out yet.

It’s sad but we are all victims of years of medical arts brain washing. As a paramedic educator, it took me years to come to grips with this. You are not cheating! You are augmenting your physical exam (which is not as accurate as you think). The ultrasound probe can be applied as lovingly as the stethoscope. You can still spend time with your patients and develop the history and physical exams of your choice. This tool can help you give better care and that’s what it’s all about. If you research medical history you will find that initially, blood pressure was determined by palpation alone. It was very much an art. When the mercury sphygmomanometer came along the physicians of that time did not want to adopt the tool that made it easy. There have been several such examples along history’s timeline.

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I think that the imaging techs are becoming careless- maybe it’s that they graduate from these online schools that have limited hands on- or not so great radiologists. I’ve been burnt on myself ( a rare incurable head cancer that’s scanned every 6 months), and at the vet for my coonhound.
The Auscultation sounded like a healthy dog. She has been limping so I opted for X-Rays, which showed an enlarged heart. So, I went for the ultrasound. A perfect heart. $600. She weighs a 100 lbs, and is near the end of her breed lifespan. If that stunt is pulled again, I’ll go with the Auscultation. The X-Ray tech had her heart at the wrong angle.
I went into the X-Ray company and wanted to know why my head was at the wrong slant- X-Ray tech- maybe the same one that’s at the vet, or one that trained at the same school. Anyway my scans with contrast are compromised.

The best radiologist in the world will have trouble if the X-Rays, MRIs, Cat or PET scans are compromised. I wish that they could use a stethoscope on my poor head. She sprained an ankle when she landed on a tree ring and turned over 35 lb blocks. I know that probably nothing can be done for me, but I had the expectation of it being tracked so that my oncologists would have an idea of what’s going on.

Author

This blog isn’t about sharing information; it’s about starting conversations. And since good conversations require good listening, I decided to call this blog “Auscultation.” Ira Nash, MD, FACC, FAHA, FACP

The views expressed here are solely the personal views of Ira Nash, MD and do not necessarily represent the policy or position of Northwell Health Physician Partners, Northwell Health or any of their affiliates, employees or physicians.

About Ira Nash, MD

Ira Nash, MD is the Executive Director of Northwell Health Physician Partners, and Senior Vice President of Northwell Health, and a professor of Cardiology and Population Health at Hofstra Northwell School of Medicine.